Please fill out this form completely and submit. If you have any questions, please e-mail us. Confirmation will be sent to you via e-mail. The prices on this page are for U.S. deliveries only.
PRODUCT INFORMATION
Option 1 -Support YOU! Insoles
$55 - $65 per pair
Childrens by quote
Option 2 - Adjust YOU! Insoles
$55 - $65 SOLEMATES Insoles™
Adjust YOU - $40.00
Option 3 - Premiere SOLEMATES Orthotics™
$275 mid length (First Pair)
$300 Full length (First Pair)
Childrens by quoteSecond Pair Premiere SOLEMATES Orthotics™
$150 (Second pair must be ordered at the same time)
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Number you wish to purchase
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Your Age
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Your Sex
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Your Height
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Your Weight
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In which type of shoes will you usually use these orthotics (check all that apply)
The SoleMates™ as shown, has an optional full length top cover. If this option is desired, please indicate on the bottom of the order form. The full length top cover takes up more space in the shoe. The regular sport orthotic ends just behind or proximal to the metatarsal heads.
Please describe intended uses
Do you have any these foot conditions?
Referred By
Special Instructions: (Please list specific medical problems or other pertinent information)
Will you be in need of any Footwear that can
accomidate the support sytem?
If Yes, what type of shoe would you need:
Name:
Email address:
SOLEMATES Orthotics™
Order Form
Years
Feet and Inches
